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Quality Improvement Nurse in Orange at Prospect Medical Systems

Company: Prospect Medical Systems
Location: Orange
Posted on: October 29, 2018

Job Description:

Job Description

Quality Improvement Nurse

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.Oversees the daily operations of the QI department and is responsible for the execution and coordination of all QI activities. Interfaces with other departments and Health Plans for QI issues.

Job Responsibilities/Duties

  • Quality, Grievance and Appeals / Statistical Reporting:
  • Review daily grievance and appeals from health plans, providers or members and request in writing to the appropriate facility or provider for any records and a response. Review with Medical Director on each case to determine leveling.
  • Update Grievance Appeal Logs daily and report to appropriate committees monthly.
  • Report statistical information on quality issues tracked by health plan and report monthly to the QI Committee.
  • Identify and act upon any provider/vendor trends immediately and informs Medical Director and QI Committee.
  • Prepare and develop annual QI study tools, gather and report statistical results to QI Committee, governing board and health plans. Study will be decided by QI Committee each year.
  • Participate and provide information for QI Plan and semi-annual coalitions.Implement annual QI study approved by QI Committee with policy, process flow, and action plan and report results when completed. (Access audits / coalitions / HEDIS)
  • Conduct Access and Availability audits per health plan request. Maintain departments access audits to include CSR, health plan or internal complaints.
  • Ensure access and availability log is updated weekly with trends reported to QI committee with follow-up and closure to be compliant.
  • Schedule appointments with physician offices and ancillary facilities for site reviews (facility and medical charts) as requested by the Credentialing Department.
  • Send confirmation letter with set appointment date and the site audit tool prior to appointment to provider office.
  • Report within 48 hours to the Credentialing Department the provider offices that do not meet threshold requirements for the audit and provide a copy of the review and notes after site audit is completed.

    Qualifications

    Minimum Education: High School diploma.Minimum Experience: Three to five (3 - 5) years experience in a Medical Group/Health Plan QI department.Req. Certification/Licensure: RN or LVN active, (unrestricted) license with 3 - 5 years experience in a Medical Group/Health Plan QI department.

    Employee Value Proposition

    Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:
    • Company 401K
    • Medical, dental, vision insurance
    • Paid time-off
    • Life insurance

      How to Apply

      To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.EEOC is the Law:

      10940

      Keywords: Prospect Medical Systems, Orange , Quality Improvement Nurse in Orange at Prospect Medical Systems, Healthcare , Orange, California

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